Open AccessNOBLE trial—is it time to revise the guidelines?
Author(s) -
Pradeep Narayan
Publication year - 2020
Publication title -
indian journal of thoracic and cardiovascular surgery/indian journal of thoracic and cardiovascular surgery
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.114
H-Index - 9
eISSN - 0973-7723
pISSN - 0970-9134
DOI - 10.1007/s12055-020-00965-6
Subject(s) - medicine , revascularization , conventional pci , cardiology , myocardial infarction , percutaneous coronary intervention , cardiac surgery , angioplasty , stroke (engine) , cardiothoracic surgery , hazard ratio , clinical endpoint , randomized controlled trial , stenosis , vascular surgery , surgery , confidence interval , mechanical engineering , engineering
The Nordic-Baltic-British left main revascularization trial (NOBLE) is a prospective, randomized, multicentre, non-inferiority trial comparing percutaneous coronary angioplasty (PCI) with coronary artery bypass grafting (CABG) for revascularization of patients with unprotected left main coronary artery (LMCA) stenosis. The primary outcome was a combined endpoint of all-cause mortality, stroke, non-procedural myocardial infarction and repeat revascularization. CABG was found to be superior to PCI with respect to the 5-year MACCE rates (28% vs. 19%) with a hazard ratio (HR) of 1.58 (95% CI 1.24-2.01). All-cause mortality rates were similar, but PCI was associated with increased occurrence of non-procedural myocardial infarction ( p = 0.0002) and repeat revascularization ( p = 0.0009). There was no difference in the stroke rates ( p = 0.11) at 5 years. Currently, European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines on myocardial revascularization assign a class 1A recommendation to PCI in patients with unprotected LMCA stenosis with a SYNTAX score < 23. The findings of the NOBLE trial challenge this premise.